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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 294 Results
Patient Safety Innovation November 16, 2022

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room. 

Aziz S, Barber J, Singh A, et al. J Hosp Med. 2022;17:880-887.
The introduction of new technology can have mixed consequences on staff workflows and patient safety. Focus groups of residents and nurses in a California children’s hospital sought to assess the advantages and shortcomings of secure text messaging systems (STMS) on teamwork, patient safety, and clinician well-being. Guidelines to reduce drawbacks are described.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

Tahir D. Kaiser Health News. September 26, 2022. 

Negative patient representations in medical records perpetuate stereotypes that can affect care over time. This story discusses how written notes using stigmatizing language reflect bias and physician disrespect that serve as clues to misdiagnosis. Black patients and those patients named as "difficult" were particularly vulnerable to damaging representation in notes.
Yuan CT, Dy SM, Yuanhong Lai A, et al. Am J Med Qual. 2022;37:379-387.
Patient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasized the importance of engagement in developing safety solutions. A recent PSNet perspective discusses patient safety challenges in ambulatory care, particularly during the COVID-19 pandemic.

Schnipper JL. Ann Intern Med. 2022;175(8):ho2-ho3.

Medication reconciliation is a primary method for improving the safety of medication administration in acute care. This essay highlights how individual hospitalists can improve medication reconciliation both at the practice and organizational level. Areas of influence discussed include medication history completeness and health information technology design.
Harsini S, Tofighi S, Eibschutz L, et al. Diagnostics (Basel). 2022;12:1761.
Incomplete or delayed communication of imaging results can result in harm to the patient and have legal ramifications for the providers involved. This commentary presents a closed-loop communication model for the ordering clinician and radiologist. The model suggests the ordering clinician categorize the radiology report as “concordant” or “discordant”, and if discordant, provide an explanation.
Alpert AB, Mehringer JE, Orta SJ, et al. J Gen Intern Med. 2022;Epub May 31.
Transgender patients who experience or perceive bias when receiving care may avoid or delay seeking care in the future. In this study, transgender patients reported on their experiences in viewing their electronic health record (EHR). In line with previous studies, transgender patients reported experiencing harms in several ways, such as providers using the wrong pronouns, wrong name, or wrong gender marker. The structure of the EHR (e.g., no separate fields for sex and gender) itself also created barriers to quality care.
Nanji K. UpToDate. June 23, 2022.
Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.
Giardina TD, Choi DT, Upadhyay DK, et al. J Am Med Inform Assoc. 2022;29:1091-1100.
Most patients can now access their provider visit notes via online portals and many have reported mistakes such as diagnostic errors or missed allergies. This study asked patients who may be “at-risk” for diagnostic error about perceived concerns in their visit notes. Patients were more likely to report having concerns if they did not trust their provider and did not have a good feeling about the visit. Soliciting patient concerns may be one way to improve transparency regarding diagnostic errors and trust in providers.
Schust G, Manning M, Weil A. J Gen Intern Med. 2022;37:2074-2076.
The OpenNotes concept is positioned  to increase patient engagement in their care through error correction and communication enhancement. This commentary highlights concerns associated with privacy involving certain conditions and patient groups that participate in open notes programs. The authors provide recommendations to ensure safety while enabling effective information sharing with all patient populations.
Nguyen OT, Hong Y-R, Alishahi Tabriz A, et al. Appl Clin Inform. 2022;13:242-251.
The 21st Century Cures Act mandates that most health care organizations provide patients access to their health record upon request. Using survey data collected just prior to implementation of the Cures Act, researchers found approximately 6.5% of patients requested changes to errors identified in their health records. Patients who reported frequent visits to their online portal and patients who reported entering data into the portal had greater odds of requesting a correction.
Zomerlei T, Carraher A, Chao A, et al. J Patient Saf Risk Manage. 2021;26:221-224.
Failure to communicate abnormal test results to patients can lead to significant health complications and medical malpractice claims. This study aimed to increase patient engagement in asking their provider about previously obtained diagnostic test results. Reminders to follow up with their provider about test results were sent to the patient via the after-visit summary and patient portal. Patients receiving reminders were up to 20 times more likely to ask their providers about their test results, compared to patients who did not receive reminders.
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...
Gadallah A, McGinnis B, Nguyen B, et al. Int J Clin Pharm. 2021;43:1404-1411.
This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department.  The rates of unintentional discrepancies per medication and incomplete medication histories were significantly lower for vCPhT than other clinicians. Length of stay, readmissions, and emergency department visits were similar for both groups.
Hofer IS, Cheng D, Grogan T. Anesth Analg. 2021;133:698-706.
Anesthesia-related adverse events have been associated with increased length of stay, morbidity and mortality. This study investigated the effect of missed documentation of select comorbidities on postoperative length of stay and mortality. Results indicate that missed documentation of one of the comorbid conditions increased risk of length of stay, and mortality was increased with missed atrial fibrillation.
Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;28:28(12).
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.